Medical Form – Lourdes Pilgrimage 2025

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Medical Team Notes

Name(Required)

Prefix First Last

Contact Number(Required)

By providing these details, you agree to being contacted by this method.

Contact Email(Required)

By providing these details, you agree to being contacted by this method.

Do you have a medical condition / disability / restricted mobility?(Required)

Yes

Age at time of travel

Please put your age as of 25th July 2025

Doctor's Name(Required)

Doctor's Telephone Phone(Required)

GP Address(Required)

Street Address Address Line 2 City Post Code Country

Medical Form Section 1 – Healthcare Contact Details

Hospital / NHS Number

Do you have a Hospital Consultant or other Clinical Team?

Yes

Hospital Consultant / Clinical Team Name

Hospital Consultant / Clinical Team Telephone

By you providing these details, they agree to being contacted by this method.

Medical Form Section 2 – Travel Arrangements

In the UK

Are you being taken to, or collected from, an airport/train station in the UK?

Yes

Person taking you to departure point in UK

Contact Number

By you providing these details, they agree to being contacted by this method.

Person collecting you on arrival to UK

Contact Number

By you providing these details, they agree to being contacted by this method.

During Travel

Mobility needs during travel

I require wheelchair assistance for specific movements in and around the airport, but can walk up and down stairs and move about inside the aircraft.

I require wheelchair assistance at all times except within the aircraft; I cannot walk up and down stairs.

I am completely immobile, rely on a wheelchair for all movement, and require continuous assistance from arrival at the airport to seating in the aircraft, including special seat accommodations.

Please choose the description which matches your needs. This will be used by Tangney to provide assistance in the terminal and aboard the flight.

Do you need a wheelchair?

Yes and will bring my own

Yes but won’t bring my own

Will someone assist you with your wheelchair during travel and in Lourdes?

Yes

Person assisting you

Contact details for person assisting

By you providing these details, they agree to being contacted by this method.

Mobility aid details

Please provide the make, model, dimensions (folded & unfolded), weight and battery type of any powered or non-collapsible mobility aids

In Lourdes

Do you require assistance in Lourdes

Yes

i.e. from a Redcap

Other needs in Lourdes

Deaf BSL user

Hearing aid user

Deaf/blind

I cannot walk 10 steps unaided

I cannot walk a mile unaided

Please select all that apply.

Please indicate where you will be staying in Lourdes

Medical Form Section 2 – Medical History

Medical Conditions / Illnesses

List all your Medical Conditions / Illnesses and date started.

Medication

Please list: 1. Name of Medication 2. Dose/number of tablets 3. How often? Use the document upload option on the final page if you have lots of medical documentation.

Allergies

If you have an allergy to any medication, food stuff or product, please provide the details here, including the reactions you have as a result of them.

Support and care needs

I get help at home

I am able to care for myself and do not need assistance

What sort of help do you receive at home?

To wash and dress

To make my meals

To help me eat and drink

To use the toilet

To get into or out of bed

To move around

Please select all that apply

Do you have a Care Package at home?

Yes

Do you have 24-hour care support?

Yes

How many times a day?

How many days a week?

Name of Care Provider

Contact number of Care Provider

By you providing these details, they agree to being contacted by this method.

Email of Care Provider

By you providing these details, they agree to being contacted by this method.

I use specialist equipment at home

Yes

Please state what equipment is used

e.g. hoist, specialist bed.

My home has adaptations to assist with my care

Yes

Adaptations

Please state what adaptations have been made to your home

I have regular visits from a healthcare professional

Yes

e.g. Doctor, Community Nurse, Therapist

Health Care Professional details and how often they visit

Have you seen your GP within the past 3 months?

Yes

Please state how many times and the reasons for the visit/s

Have you needed to contact NHS 111 within the past 3 months?

Yes

Please state how many times and for what reason/s.

Have you needed to attend an emergency department/urgent care centre for your medical condition/s or had any hospital admissions in the past 3 months?

Yes

Please state why and what treatment you received, and if this was this for an existing or new condition.

Medical Information Upload

Please upload any relevant medical documents.

Drop files here or

Accepted file types: pdf, doc, docx, img, png, jpg, jpeg, Max. file size: 16 MB.

Is there anything else you need to tell us? Please use the blank space below.

Protecting your privacy:

Your personal details will be stored and used by the Diocese of Westminster for the purposes of running and administering the Lourdes Pilgrimage. Details of how the Diocese processes your data, and your rights, are in the full privacy notice, which can be found at: https://rcdow.org.uk/privacy/.

The medical information you have provided must be shared with the Pilgrimage Medical Team for the purposes of running and administering the pilgrimage. By submitting this form, you are indicating that:

You have provided accurate information about any medical condition(s), restricted mobility, or disability/ies you have;
You consent to the Pilgrimage Team contacting any of your pre-existing healthcare professionals for the assessment of your health and medical needs during the Pilgrimage;
And that you consent to the sharing of any medical information with other healthcare professionals, either in France or the UK, in the interests of ensuring your on-going health and medical needs are met.

Additionally, for those who are booking a pilgrimage package or Lourdes accommodation through Westminster Diocese and Tangney Tours, the mobility needs you have provided must be shared with our tour operator, Tangney Tours, for the purposes of running and administering the pilgrimage. By submitting this form, you are indicating that:

You have read, understood the Tangney Tours’ Booking Terms & Conditions and that you accept them on your own behalf and/or are authorised to accept them on behalf of the other travellers named on the form.